INTRODUCTION:
A hiatus hernia occurs when part of the stomach protrudes through the oesphageal opening of the diaphragm into the chest. This condition can cause discomfort and affect daily life. In this article, we will explore the types, symptoms, diagnostic methods, and management options for hiatus hernia.
What Is Hiatus Hernia?
The oesophagus (food pipe) enters the abdomen through the diaphragmatic hiatus, a small opening in the diaphragm. The diaphragm acts as a barrier between the chest and abdomen. When the hiatus widens it allows for mainly the stomach and rarely other organs also to move up from the abdomen into the chest and that is called a hiatus hernia.
SYMPTOMS:
The most common symptom of hiatus hernia is gastro-oesophageal reflux (heartburn and regurgitation). Other less common symptoms include:
Dysphagia (difficulty swallowing)
Epigastric or chest pain
Chronic cough
Chronic iron deficiency anemia due to minor bleeding
Major bleeding – Haematemesis &/or Malena
Repeated Respiratory infections
TYPES OF HIATUS HERNIA:
Sliding Hiatal Hernia (Type I):
Incidence: Sliding hiatal hernias are the most common, accounting for approximately 90-95% of all hiatus hernias.
Description: In this type, the gastro-oesophageal junction (GEJ) slides upwards through the diaphragmatic hiatus.
Clinical Significance: Sliding hernias are often associated with gastro-oesophageal reflux disease (GERD).
Management: Treatment focuses on lifestyle modifications, medications, and occasionally surgical intervention.
Para-oesophageal Hiatal Hernia (Type II):
Incidence: Paraoesophageal hernias constitute about 1% of all hiatus hernias.
Description: In paraoesophageal hernias, the GEJ remains in its usual position, but the gastric fundus rolls upwards through the widened hiatus.
Clinical Significance: These hernias can be large and may lead to complications such as volvulus, obstruction, and ischemia.
Diagnostic Approach: CT scans with oral contrast agents are recommended when type III or IV hernias are suspected.
Mixed Hiatal Hernia (Type III):
Incidence: Mixed hernias account for a small percentage of cases (approximately 5%).
Description: Type III hernias involve both sliding and paraoesophageal components. There is herniation of the cardiac and fundus parts of the stomach, along with sliding of the GEJ upwards.
Clinical Implications: These hernias may present with a combination of symptoms related to reflux and mechanical obstruction.
Surgical Considerations: Surgical management can be challenging due to the need for relocating hernial contents, repairing diaphragmatic defects, and occasionally shortening the oesophagus (Collis gastroplasty).
This elderly gentleman presented with acute shortness of breath and heaviness in the chest. Xray showed a large hiatus hernia in the chest. A ryle's tube was inserted immediately and the patient's symptoms completely settled. He later underwent a Laparoscopic Fundoplication by me. He is symptom free on 1 year of follow up.
Other organs besides the stomach in the chest (Type IV):
Incidence: Type IV hernias are relatively rare.
Description: They usually involve herniation of the stomach and other organs like omentum, small bowel, colon, spleen, etc.
Clinical Importance: Large paraoesophageal hernias increase the risk of complications.
Treatment: Laparoscopic fundoplication is the standard surgical approach to restore lower oesophageal sphincter function. A Mesh repair or crural releases may be required.
DIAGNOSIS:
1.Clinical Evaluation: Physicians assess symptoms and perform physical examinations.
2.Endoscopy: A flexible tube with a camera is inserted through the mouth to visualize the oesophagus and stomach.
3.Xray, Flouroscopy with Barium Swallow: Patients swallow a barium solution, allowing X-rays to detect hernias.
4.High-Resolution Manometry: Measures oesophageal pressure and function.
5.24 Hour pH Studies
Xray showing a huge hiatus hernia with an explanation on the right.
Barium swallow of a hiatus hernia
MANAGEMENT:
Medical Management
Lifestyle Modifications:
Elevate the head of the bed.
Avoid large meals before bedtime.
Lose weight if overweight.
Quit smoking.
Medications:
Antacids: Neutralize stomach acid.
Proton Pump Inhibitors (PPIs): Reduce acid production.
H2 Blockers: Decrease acid secretion.
Surgical Management
Indications for Surgery:
o Severe symptoms not controlled by medications.
o PPI dependance
o Complications (e.g., bleeding, strictures).
o Surgical Procedures:
All the procedures below can be done via the open surgical repair, laparoscopic or robotic methods as per the patient and the surgeons skill. The surgery consists of 2 parts:
Hernia Repair: Repositions the herniated stomach and reinforces the diaphragm. If the defect is large and the crural muscles of the diaphragm are weak, the surgeon may opt for a mesh to reinforce the hiatus to prevent a recurrence.
Fundoplication: Wraps the top of the stomach around the lower oesophagus to prevent reflux (by acting like a valve) and migration of the wrap into the chest.
Types of Fundoplication:
1. Nissen Fundoplication (360° wrap): In this procedure, the entire lower end of the esophagus is wrapped by the fundus (the upper part of the stomach that bulges around the esophagus).
2. Toupet Fundoplication (270° wrap): Here, two-thirds of the back of the lower part of the esophagus is wrapped by the fundus.
3. Watson or Dor Fundoplication (180° wrap): In this type, half of the anterior portion of the lower end of the esophagus is wrapped by the fundus
Risks and Benefits of Surgery
Surgical Risks:
o Infection
o Bleeding
o Difficulty swallowing – Dysphagia
o Gas bloat and increased flatulence
Benefits:
o Improved quality of life
o Reduced reflux symptoms
o Less incidence of aspiration in sleep causing chronic cough
o Reduced micro-aspiration and lung fibrosis which is irreversible.
CONCLUSION:
Hiatus hernia is a common condition that affects many individuals. Early diagnosis and appropriate management can alleviate symptoms and prevent complications. Excellent medical and surgical treatment options are available today for their treatment as per the type of hiatus hernia.
Youtube links to our hiatus hernia surgeries:
For lots more surgical videos please view my Youtube channel below.
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DNB (Gen. Surg.), F.MAS, FIAGES, FALS(Hernia), FALS (Colo-rectal)
Consultant Laparoscopic & General Surgeon
Bhatia Hospital, Breach Candy Hospital, B. D. Petit Parsee General Hospital, Masina Hospital, ACI Cumballa Hill Hospital & Conwest & Manjula S. Badani Jain Hospital.
Mumbai, India
Mob: +91 9833109876; For Appointments: +9122 66660234 or click here
E-mail: ksd@drksdastoor.com Website: www.drksdastoor.com
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